Blood Pressure of Maintenance Hemodialysis Patients in the Dalmatian Region of Croatia: Differences between Hospital and Out-of-Hospital Dialysis Centers.

AIMS: This study was aimed at comparing the incidence of arterial hypertension and blood pressure (BP) variance in hospital and out-of-hospital hemodialysis (HD) patients during HD sessions. METHODS: A cross-sectional study was conducted for 1 week at all the HD centers in Dalmatia, Croatia. The pre-, intra-, and post-dialysis BP values were collected for 3 consecutive HD sessions per patient. RESULTS: Of the 399 subjects, 73.9% were hypertensives, who showed higher interdialytic weight gain compared to the normotensives (2.58 vs. 2.40). Hospital and out-of-hospital HD patients received identical antihypertensive therapies, except that beta blockers were more frequently administered to out-of-hospital HD patients. Higher pre-, intra-, and post-dialysis BP values were recorded in patients at out-of-hospital HD centers. CONCLUSION: The differences in BP variability and antihypertensive therapies administered to hospital HD patients as compared to out-of-hospital HD patients may reflect differing approaches by the nephrologists at these centers.

Expression of BMP-2 in Vascular Endothelial Cells of Recipient May Predict Delayed Graft Function After Renal Transplantation.

BACKGROUND/AIMS: Delayed graft function (DGF) is associated with adverse outcomes after renal transplantation. Bone morphogenetic protein-2 (BMP-2) is involved in both endothelial function and immunological events. We compared expression of BMP-2 in epigastric artery of renal transplant recipients with immediate graft function (IGF) and DGF. METHODS: 79 patients were included in this prospective study. Patients were divided in IGF group (64 patients) and DGF group (15 patients). BMP-2 expression in intima media (BMP2m) and endothelium (BMP2e) of epigastric artery was assessed by immunohistochemistry. RESULTS: Lower intensity of BMP2e staining was recorded in DGF compared to IGF. In DGF patients, 93% had no expression of BMP2e and 7% had 1st grade expression, compared to 45% and 41% in IGF group, respectively (P=0.001) (P<0.001 for no expression and P = 0.015 for 1st grade expression). Patients who had BMP2e staining positive had lower odds for DGF (OR 0.059 [0.007, 0.477]) and this remained significant even after adjustment for donor and recipient variables, cold ischemia time, and immunological matching (OR 0.038 [0.003, 0.492]). CONCLUSIONS: Our results demonstrate that BMP-2 expression in endothelial cells of epigastric arteries may predict development of DGF.

[[GUIDELINES FOR THE PREVENTION, MONITORING AND THERAPY OF CHRONIC KIDNEY DISEASE-METABOLIC BONE DISEASE IN PATIENTS WITH CHRONIC KIDNEY DISEASE].]

Chronic kidney disease (CKD) is a systemic disease with numerous complications associated with increased morbidity and mortality. Chronic kidney disease-metabolic bone disease (CKD-MBD) starts at early stages of CKD with phosphorus accumulation and consequent initiation of numerous events that result with the development of secondary hyperparathyroidism with changes on bones and extraskeletal tissues. The most important and clinically most relevant consequences of CKD-MBD are vascular calcifications which contribute to cardiovascular mortality. Patients with the increased risk for the development of CKD-MBD should be recognized and treated. Prevention is the most important therapeutic option. The first step should be nutritional counseling with vitamin supplementation if necessary and correction of mineral status. Progression of CKD requires more intensive medicamentous treatment with the additional correction of metabolic acidosis and anemia. Renal replacement therapy should be timely initiated, with the adequate dose of dislaysis. Ideally, preemptive renal transplantion should be offered in individuals without contraindication for immunosuppressive therapy.

[Croatian guidelines for screening, prevention and treatment of protein-energy wasting in chronic kidney disease patients]. / Preporuke za pracenje, prevenciju i lijecenje proteinsko-energijske pothranjenosti u bolesnika s kronicnom bubrezom bolesti.

There is a high incidence of cardiovascular morbidity and mortality among patients with chronic kidney disease (CKD) and malnutrition is a powerful predictor of cardiovascular morbidity and mortality in this population of patients. A multitude of factors related to CKD and renal replacement therapy can affect the nutritional status of CKD patients and lead to the development of malnutrition. In patients with CKD, protein energy wasting (PEW) is a condition that is distinct from undernutrition and is associated with inflammation, increased resting energy expenditure, low serum levels of albumin and prealbumin, sarcopenia, weight loss and poor clinical outcomes. Nutritional and metabolic derangements are implicated for the development of PEW in CKD and leading to the development of chronic catabolic state with muscle and fat loss. Prevention is the best way in treating PEW. Appropriate management of CKD patients at risk for PEW requires a comprehensive combination of strategies to diminish protein and energy depletion, and to institute therapies that will avoid further losses. The mainstay of nutritional treatment in MHD patients is nutritional counselling and provision of an adequate amount of protein and energy, using oral supplementation as needed. Intradialytic parenteral nutrition and total enteral nutrition should be attempted in CKD patients who cannot use the gastrointestinal tract efficiently. Other strategies such as anemia correction, treatment of secondary hyperparathyroidism and acidosis, delivering adequate dialysis dose can be considered as complementary therapies in CKD patients. Multidisciplinary work of nephrologists, gastroenterologist and dietician is needed to achieve best therapeutic goals in treating CKD patients with PEW.

[Infections during the first posttransplant year--experience at Sibenik General Hospital]. / Infektivne komplikacije u primatelja bubrega tijekom prve godine nakon transplantacije: iskustvo zupanijske bolnice Sibenik.

AIM: The aim of this study was to assess the frequency and type of infective complications in kidney recipients during the first year after transplantation. PATIENTS AND METHODS: We retrospectively analyzed data on the diagnosis and treatment of infective complications in 36 patients transplanted from 2004 until September 2012 (22 men and 14 women), age at the time of transplantation 19-73 years. We recorded the incidence of urinary tract infections, clinical variants (asymptomatic bacteriuria, acute pyelonephritis, sepsis) and etiology, i.e. causes, pneumonia, viral infections and cytomegalovirus infections (CMV) (with special reference to the use or no use of prophylactic valganciclovir), polyoma virus infection, BKV, JC, Epstein-Barr virus, and herpes zoster virus. RESULTS: The most common infective complication, uroinfection, was recorded in 69% of patients, of which 68% had one or more relapses. The most common clinical form of the infection was acute tubulointerstitial nephritis, caused by Klebsiella pneumoniae (of which 4 cases of ESBL Klebsiella pneumoniae). Pneumonia occurred in 4 transplant patients, one CMV pneumonia, other of bacterial origin. CMV infection and BKV occurred in 17% and herpes zoster infection in 11% of patients. One patient was diagnosed with EBV meningoencephalitis. One-year graft survival was 100% in patients without urinary tract infections in the first year after transplantation (31% of all patients) and 96% in patients with infections (69% of all patients).Three-year graft survival rate was 100% in patients without infection and 96% in patients with infections in the first year after transplantation. One- and three-year graft survival in patients with chronic hepatitis C was 100%. It was a small group of patients (5/36, 14%); the incidence of urinary tract infections amounted to 60%, and of CMV and BK virus to 20%. CONCLUSION: Infections are a common problem after kidney transplantation, which can be treated in a secondary care hospital.

[How to prevent protein-energy wasting in patients with chronic kidney disease--position statement of the Croatian Society of Nephrology, Dialysis and Transplantation]. / Kako prevenirati i lijeciti proteinsko-energetsku pothranjenost u bolesnika s kronicnom bolescu bubrega--osvrt hrvatskog drustva za nefrologiju, dijalizu i transplantaciju na preporuke medunarodnog drustva za prehranu bubreznih bolesnika.

Protein-energy wasting (PEW) is a frequent problem in patients with end-stage renal disease, which is associated with adverse outcome. Risk factors for development of PEW in dialysis patients include anorexia, limitations in food intake due to problems with mineral metabolism (hyperphosphatemia, hyperkalemia). Prevention of PEW in dialysis population demands different therapeutic measures to correct abnormalities and to prevent loss of energy and proteins. Therapeutic approach should be individualized based on the specific problems of each patient in order to correct metabolic problems and to optimize food intake. In patients with inability to maintain nutritional status with standard oral feeding, other measures which include oral nutrition supplements and intradialytic parenteral feeding should be applied. Anabolic steroids, growth hormone and adequate oral nutritional supplements, together with physical activity may prevent further catabolism and correct abnormalities. Appetite stimulators, antiinflammatory interventions and anabolic drugs seem promising; however, their efficacy should be investigated in future clinical trials.

[Treatment of anemia in chronic kidney disease--position statement of the Croatian Society for Nephrology, Dialysis and Transplantation and review of the KDIGO and ERPB guidelines]. / Lijecenje anemije u kronicnoj bubreznoj bolesti--stav hrvatskog drustva za nefrologiju, dijalizu i transplantaciju i osvrt na preporuke KDIGO i ERBP.

Renal anemia is the result of chronic kidney disease (CKD) and deteriorates with disease progression. Anemia may be the first sign of kidney disease. In all patients with anemia and CKD, diagnostic evaluation is required. Prior to diagnosing renal anemia, it is necessary to eliminate the other possible causes. Direct correlation between the concentration of hemoglobin and the stage of renal failure is well known. Early development of anemia is common in diabetic patients. Correction of anemia may slow the progression of CKD. Anemia is an independent risk factor for developing cardiovascular disease in patients with CKD. Treatment of anemia in patients with CKD is based on current guidelines. Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anemia in CKD patients and ERBP (European Renal Best Practice) group its position statement and comments on the KDIGO guidelines. The Croatian Society of Nephrology, Dialysis and Transplantation (HDNDT) has already published its own guidelines based on the recommendations and positive experience of European and international professional societies, as well as on own experience. The latest version of Croatian guidelines was published in 2008. Since then, on the basis of research and clinical practice, there have been numerous changes in the modern understanding of the treatment of anemia in CKD. Consequently, HDNDT hereby publishes a review of the recent recommendations of international professional societies, expressing the attitude about treating anemia in CKD as a basis for new guidelines tailored to the present time.

Pegylated interferon for treatment of chronic hepatitis C in hemodialysis patients in Croatia.

BACKGROUND AND AIMS: Hepatitis C virus (HCV) infection is a frequent complication among long-term dialysis patients. The aim of the present study was to evaluate the efficacy and side effects of pegylated interferon-α(2a) (PEG-IFN-α(2a)) treatment in hemodialysis patients. METHODS: We retrospectively reviewed charts of 16 HCV-RNA-positive hemodialysis patients. RESULTS: There were 11 male and 5 female patients treated with dialysis for 6-28 years. Twelve patients had HCV genotype 1b, 2 patients had 3a, and 1 patient had genotype 2a. Although only 10 out of 16 patients completed 48 weeks of treatment, early virological response and end-of-treatment virological response were achieved in 9 and 13 patients, respectively. Sustained virological response was recorded in 9 patients. The most common side effect was anemia. A flu-like syndrome was documented in 6, myalgia in 4, and arthralgia in 5 patients. Rectorrhagia, endocarditis and severe cough were recorded in 1 patient each. Nine patients received a renal transplant, and all 6 responders remained HCV-RNA-negative. CONCLUSIONS: PEG-IFN-α(2a) has limited efficacy in dialysis patients. A significant proportion of patients discontinued treatment because of side effects. Additional studies with long-term follow-up are needed to determine the optimal treatment of HCV infection in the dialysis population.

[Outcome of renal transplantation in patients with chronic virus hepatitis]. / Ishod transplantacije bubrega u bolesnika s kronicnim virusnim hepatitisom.

The objective is to present results of renal transplantation in patients with end-stage renal disease and chronic virus C/B hepatitis. We retrospectively reviewed outcome of transplantation in patients having received renal allograft from 1985 to 2009 at Zagreb University Hospital Center: graft function, graft and patient survival, hepatic function, and complications of transplantation, i.e. episodes of acute rejection, manifestation of diabetes mellitus, and proteinuria. There were 91 patients, 50 men and 41 women, mean age 40.9. Patients were previously treated with dialysis for 7.8 years, with the mean follow-up after transplantation of 7.3 years. The most frequent diagnoses of end-stage renal disease were chronic glomerulonephritis, reflux nephropathy, tubulointerstitial nephritis, renal hypoplasia/aplasia, and polycystic renal disease. Good graft function (creatinine 200 micromol/L) was recorded in 59.5% of patients. One-year, 5-year and 10-year graft survival was 93%, 64% and 39%, and 1-year, 5-year and 10-year patient survival after transplantation was 98%, 72% and 42%, respectively. Normal values of liver chemistry (AST, ALT) were found in 59.5% and elevated values in 40.5% of patients. Episodes of acute rejection occurred in 56% of patients. Proteinuria was recorded in 27%, diabetes mellitus in 18% and elevated blood pressure in 66% of patients. Patients with chronic C/B virus hepatitis having undergone renal transplantation had worse graft function and worse graft and patient survival than patients without chronic hepatitis. The most common causes of death were cardiovascular diseases, cerebrovascular diseases and cirrhosis hepatitis.

Seroepidemiology of hepatitis E in patients on haemodialysis in Croatia.

PURPOSE: Data on the seroprevalence of hepatitis E virus (HEV) in heamodialysis (HD) patients are conflicting, ranging from 0 to 44%. The aim of this study was to determine the HEV seroprevalence and risk factors among HD patients in Croatia. METHODS: A total of 394 HD patients from six medical facilities in five Croatian cities (three sites in the continental and three sites in the coastal region) were tested for HEV IgM/IgG antibodies using an enzyme-linked immunosorbent assay. Additionally, all samples were tested for HEV RNA by RT-PCR. Sociodemographic data and risk factors were collected using a questionnaire. RESULTS: HEV IgG antibodies were detected in 110 (27.9%) patients. The seroprevalence varied significantly between dialysis centres, ranging from 5.2 to 43.4% (p = 0.001). HEV IgM antibodies were found in 0.04% of IgG positive patients. All patients tested negative for HEV RNA. Factors associated with HEV IgG seropositivity were age > 60 years (OR 8.17; 95% CI 1.08-62.14), living in the continental parts of the country (OR 2.58; 95% CI 1.55-4.30), and transfusion of blood products (OR 1.66; 95% CI 1.01-2.73). After adjusting for age and gender, patients from continental regions had higher odds of HEV seropositivity compared to patients from coastal regions (OR 2.88; 95% CI 1.71-4.85) and those who had RBC transfusions (OR 1.70, 95% CI 1.02-2.69) compared to those who did not. CONCLUSION: The study showed a high HEV seropositivity among HD patients in Croatia, with significant variations between geographical regions. Continental area of residence and RBC transfusion were the most significant risk factors for HEV seropositivity. Due to the high seroprevalence, routine HEV screening among HD patients, especially in transplant candidates should be considered.

Anemia Is Correlated with Malnutrition and Inflammation in Croatian Peritoneal Dialysis Patients: A Multicenter Nationwide Study.

Malnutrition, inflammation, and anemia are common in peritoneal dialysis (PD) patients. In this study, correlations between Malnutrition Inflammation Score (MIS), laboratory and anthropometric parameters, and anemia indices in Croatian PD patients were analyzed. One hundred and one PD patients (males/females 54/47, age 58.71 ± 14.68 years, mean PD duration 21.82 ± 21.71 months) were included. Clinical, laboratory, and anthropometric parameters were measured. Statistically significant correlations between MIS and erythropoietin weekly dose per kg of body weight (ESA weekly dose), hemoglobin (Hb), and erythrocytes were found (r = 0.439, p < 0.001; r = -0.032, p < 0.001; r = -0.435, p < 0.001), respectively. Also, statistically significant correlations were found between MIS and mean corpuscular volume (r = 0.344, p < 0.001), iron (r = -0.229, p = 0.021), and total iron binding capacity (TIBC) (r = -0.362, p < 0.001), respectively. Furthermore, statistically significant correlations between ESA weekly dose and serum albumin level and body mass index (BMI) were found (r = -0.272, p = 0.006; r = -0.269, p = 0.006), respectively. When we divided PD patients into 2 groups according Hb level (Hb ≥ 110 [N = 60, 59.41 %]) and Hb < 110 [N = 41, 40.59%]), statistically significant differences were found in MIS score (3.02 ± 2.54 vs 4.54 ± 3.54, p = 0.014), C-reactive protein (CRP) (3.52 ± 6.36 vs 7.85 ± 7.96, p = 0.005), and serum albumin level (44.22 ± 8.54 vs 39.94 ± 8.56, p = 0.003), respectively. Our findings suggest that anemia is correlated with malnutrition and inflammation in Croatian PD patients. Further studies are needed to assess whether modulating inflammatory or nutritional processes can improve anemia management in PD patients.